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Arch Surg. 2009;144(5):481-482. doi:10.1001/archsurg.2009.64-b.
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ANSWER: CHOLECYSTOCOLONIC FISTULA ASSOCIATED WITH ESCHERICHIA COLI LIVER ABSCESS

The cholecystocolonic fistula (CCF) represents 15% of all cholecystoenteric fistulas, thus being the second most frequent after the colecysto-duodenal fistula.1Unlike fistulas between the gallbladder and proximal gastrointestinal tract, often revealed by intestinal obstruction, more than 90%2of CCF cases are discovered during laparoscopic cholecystectomy. Such misdiagnosis may result in a challenging situation for the surgeon, who must achieve a diagnosis, usually while managing multiple adhesions, and must switch from a very low-morbidity surgery, sometimes during laparoscopy, to a procedure that is harder to perform and is usually in older patients with comorbidities.

In fact, symptoms of CCF are nonspecific, thus being neglected for years. Diarrhea1,3,4due to the malabsorption of biliary acids that bypass the terminal ileum and Bahuin valve, and right hypochondrium pain1,5are the most frequent symptoms of CCF, although their lack of specificity reduces their usefulness. Jaundice and hyperpyrexia are more helpful because they may prompt exploration of the liver and hepatic loggia, but they are rare.3,4Although rarer than in cases of more proximal fistulas, emergency complications such as obstruction,5,6massive bleeding,7or hepatic abscess8have also been described and may help preoperatively achieve a correct diagnosis.

Of the proposed diagnostic means, barium enema4and endoscopic retrograde cholangiopancreatography (ERCP)3,4present a significant number of false negatives (barium enema,3,6ERCP1,4), are relatively invasive (ERCP, colonoscopy), or may not be considered routine (ERCP, scintigraphy) for patients with nonspecific symptoms. The CT scan may help diagnose CCF5,7in the case of precipitating complications such as bleeding,7biliary ileus,5or hepatic abscess. In this case, the 2-dimensional image allowed us to identify the hepatic abscess and pneumobilia in the gallbladder (Figure 1), whereas the 3-dimensional CT reconstruction showed the fistula to be between the gallbladder and colon (Figure 2), allowing us to plan the most appropriate procedure.

Place holder to copy figure label and caption
Figure 1

. Computed tomographic scan (2-dimensional) of the abdomen shows a 5-cm abscess of fourth hepatic segment associated with pneumobilia.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2

. Computed tomographic reconstruction (3-dimensional) of the abdomen shows a fistula between the gallbladder and the right transverse colon.

Graphic Jump Location

Many treatments of CCF exist, depending on the clinical picture. If the patient does not have gallstone ileus and the symptoms are strictly linked to CCF or if CCF is accidentally discovered at surgery, cholecystectomy and tangential transverse colon resection is proposed as a 1-stage procedure that may be accomplished by laparoscopy.1,3If a concomitant hepatic abscess is present, it should be surgically drained.8Conversely, if CCF is revealed by biliary ileus, it may be treated with operative colonoscopy9or enterolithotomy.5,6Depending on the conditions of the colon, a temporary colostomy may also be indicated.5Whether in older debilitated patients CCF should be treated at the same time10as a delayed procedure5or not at all6is still widely debated.

Our patient underwent a right subcostal incision and a difficult adhesiolysis. During the dissection, a sclerotic gallbladder, firmly adherent to the right transverse colon, was opened and a 1.5-cm faceted gallstone was extracted. Cholecystectomy was performed and the colon was tangentially resected by linear stapler; an intraoperative transcystic cholangiography showed no abnormalities. The hepatic collection was drained and a wide fenestration performed. Postoperative course was uneventful, and the patient was discharged on postoperative day 8.

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Correspondence:Renato Costi, MD, PhD, Dipartimento di Scienze Chirurgiche, Iniversità degli Studi di Parma, Via Gramsci 14, 43100 Parma, Italia (renatocosti@hotmail.com).

Accepted for Publication:October 23, 2008.

Author Contributions:Study concept and design: Costi, Bataille, and Cazaban. Analysis and interpretation of data: Costi and Montariol. Drafting of the manuscript: Costi, Bataille, and Cazaban. Critical revision of the manuscript for important intellectual content: Montariol. Administrative, technical, and material support: Cazaban. Study supervision: Costi and Montariol.

Financial Disclosure:None reported.

Ibrahim  IMWolodiger  FSaber  AADennery  B Treatment of cholecystocolonic fistula by laparoscopy. Surg Endosc 1995;9 (6) 728- 729
PubMed
Chowbey  PKBandyopadhyay  SKSharma  AKhullar  RSoni  VBaijal  M Laparoscopic management of cholecystoenteric fistulas. J Laparoendosc Adv Surg Tech A 2006;16 (5) 467- 472
PubMed
Caroli-Bosc  FXFerrero  JMGrimaldi  CDumas  RArpurt  JPDelmont  J Cholecystocolic fistula. Gastroenterol Clin Biol 1990;14 (10) 767- 770
PubMed
Hession  PRRawlinson  JHall  JRKeating  JPGuyer  PB The clinical and radiological features of cholecystocolic fistulae. Br J Radiol 1996;69 (825) 804- 809
PubMed
Mittendorf  EAGoel  ASeaman  D Image of the month: cholecystocolonic fistula. Arch Surg 2004;139 (8) 907
PubMed
Swinnen  LSainte  T Colonic gallstone ileus. J Belge Radiol 1994;77 (6) 272- 274
PubMed
Singh  AKGervais  DMueller  P Cholecystocolonic fistula: serial CT imaging features. Emerg Radiol 2004;10 (6) 301- 302
PubMed
Seto  HWatanabe  NKageyama  M  et al.  Concurrent detection of cholecystocolic fistula and hepatic abscess by hepatobiliary scintigraphy. Ann Nucl Med 1995;9 (2) 93- 95
PubMed
Patel  SAEngel  JJFine  MS Role of colonoscopy in gallstone ileus: a case report. Endoscopy 1989;21 (6) 291- 292
PubMed
Bornet  GChiavassa  HGaly-Fourcade  D  et al.  Biliary colonic ileus. J Radiol 1998;79 (12) 1499- 1502
PubMed

Figures

Place holder to copy figure label and caption
Figure 1

. Computed tomographic scan (2-dimensional) of the abdomen shows a 5-cm abscess of fourth hepatic segment associated with pneumobilia.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2

. Computed tomographic reconstruction (3-dimensional) of the abdomen shows a fistula between the gallbladder and the right transverse colon.

Graphic Jump Location

Tables

References

Ibrahim  IMWolodiger  FSaber  AADennery  B Treatment of cholecystocolonic fistula by laparoscopy. Surg Endosc 1995;9 (6) 728- 729
PubMed
Chowbey  PKBandyopadhyay  SKSharma  AKhullar  RSoni  VBaijal  M Laparoscopic management of cholecystoenteric fistulas. J Laparoendosc Adv Surg Tech A 2006;16 (5) 467- 472
PubMed
Caroli-Bosc  FXFerrero  JMGrimaldi  CDumas  RArpurt  JPDelmont  J Cholecystocolic fistula. Gastroenterol Clin Biol 1990;14 (10) 767- 770
PubMed
Hession  PRRawlinson  JHall  JRKeating  JPGuyer  PB The clinical and radiological features of cholecystocolic fistulae. Br J Radiol 1996;69 (825) 804- 809
PubMed
Mittendorf  EAGoel  ASeaman  D Image of the month: cholecystocolonic fistula. Arch Surg 2004;139 (8) 907
PubMed
Swinnen  LSainte  T Colonic gallstone ileus. J Belge Radiol 1994;77 (6) 272- 274
PubMed
Singh  AKGervais  DMueller  P Cholecystocolonic fistula: serial CT imaging features. Emerg Radiol 2004;10 (6) 301- 302
PubMed
Seto  HWatanabe  NKageyama  M  et al.  Concurrent detection of cholecystocolic fistula and hepatic abscess by hepatobiliary scintigraphy. Ann Nucl Med 1995;9 (2) 93- 95
PubMed
Patel  SAEngel  JJFine  MS Role of colonoscopy in gallstone ileus: a case report. Endoscopy 1989;21 (6) 291- 292
PubMed
Bornet  GChiavassa  HGaly-Fourcade  D  et al.  Biliary colonic ileus. J Radiol 1998;79 (12) 1499- 1502
PubMed

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